Turning Around the Negative '90s

The Chicago Tribune held it up to a microscope, and found it wanting. The New York Times published a whole series about it, wondering if it could be saved. The Institute of Medicine (IOM) released two reports about it (To Err is Human1 and Crossing the Quality Chasm). It is, of course, the U.S. Health Care System-or illness care nonsystem, if you want to get technical about it. After the publication of To Err is Human, safety experts testified before Congress-and blamed the changes made in hospitals in the 1990s for the increase in errors. In To Err is Human, the IOM suggested that hospitals create "a culture of safety" and those experts who testified before congress concurred-one sure way to heal this system is to change its culture.

The culture they were referring to is the corporate culture, and the healing most needed is in the organizational frame of reference, or OFOR. We commonly presume that corporations are technical, rational instruments designed to mobilize their members' efforts to achieve planned goals. In reality, they are not. Nonrational behaviors develop in interactions between and among an organization's purpose, its culture (OFOR), and its various stake holders who evaluate outcomes as they relate to their personal or groups positions. According to Shrivastava and colleagues, "Organizational Frames of Reference are contested terrain, and constitute the ideological apparatus of the organization." 2 The way an organization frames-or even defines-a problem relies upon the collective, fundamental assumptions, cognitive elements and maps, as well as the reality tests that compose-and are determined by-the OFOR. It also delineates what questions the organization explores.

Corporate culture heavily influences how well the organizations various systems (financial, clinical, and administrative) interact with one another, cope with organizational challenges, and respond to environmental (social, scientific, and financial) changes. Implicit, invisible, and informal though all corporate cultures are, they constitute the organization's self-image, and they shape its members role expectations and behavior.

By the 1980s, an aging population, coupled with astounding technological advances-and a national commitment to the care and cure of the ill-began driving costs to unanticipated heights. First came government intervention with the DRGs, and by the late 1980s, private sector-driven managed care. The conviction that costs were out of control because hospitals were poorly managed, overspecialized and staffed, and extravagant in the overuse of technology grew right along with cost increases. Thus the conviction grew that if hospitals were run on a more business-like basis, significant savings could be realized. restructuring craze of the early to late 1990s. 3

To give a short history of leadership in U.S. hospitals as an explanation: up until the 1950s, hospitals were run by the superintendent of nurses and the chief of the medical staff. However, by the late 1950s, increasing regulation and the rise of third-party payers gave impetus to the development of specialized courses in hospital administration that were housed in business schools. To graduate with their masters in hospital administration, these students were required to complete a 1- or 2-year of internship during which they rotated through hospital departments learning what they could of how a hospital operates. Generally, however, the chief of the medical staff and the director of nursing still made the decisions about patient care and its delivery.

In the late 1980s and throughout the 1990s, with the rise of managed care and government cost-cutting, the fastest way to the CEO position was to come up through the finance department-no internship, no knowledge of medicine and nursing, no understanding of how hospitals actually run-and darn little knowledge of what it takes to motivate and lead people either! Worse, hospital boards generally were peopled with individuals who also had little or no knowledge of patient care. Byzantine regulations, startling malpractice settlements, and confusing reimbursement schemes gave impetus to this movement, the upshot of which was the ascendancy of the CPA as CEO-and the subsequent adoption of a market-based, business model that imposed alien values on the hospital culture, using terms such as customer instead of patient, product lines instead of medical services, market dominance instead of community service. 4

Little attention was given to the dearth of preventive, primary, and maintenance care; the upfront costs of the biomedical revolution; or the shunting of all sorts of social problems-ranging from unwanted pregnancies, to drug addictions, and social violence, to the chronic ailments associated with aging-to the health care system. The outcome is apparent for all to see. Perhaps the greatest irony of all, is that the "business model" OFOR ended up costing more-a lot more-than the old community service model. 5

Where was nursing leadership while this was happening? The numbers tell the tale. Almost half of all nursing managers were eliminated. Nursing administrators were systematically stripped of their line authority and shunted into advisory or staff positions. Any who objected were fired. Clinical leaders, clinical nurse specialists and even physician experts (e.g., intensivists) were let go. Clinical educators were, by and large, eliminated. Anyone, in fact, who objected-or even raised a concern-was fired.

Nonetheless, nursing organizations, led by the ANA, the American Nurses Foundation, and numerous nurse researchers, began studies designed to ascertain the impact nurses and nursing had on patient outcomes and the costs of care. All in the naive belief that such facts, once gathered and couched in the proper business terms, would have an impact on organizational decision-making.

The nonrational OFOR, however, is rarely affected by facts until an outside force imposes the facts on them. And when various studies (and their own shrinking bottom lines) demonstrated that cheap care increased costs, that an undereducated and underpaid workforce increased costs, and that their reorganization and reengineering gave them a double whammy-they had paid consultants (mostly accounting firms) HUGE fees only to lose money. And the impact on the hospitals' "customer" was lethal-lethal errors more than doubled during the decade of restructuring. Serious errors increased about 1000% (by comparing the results of the Harvard Medical Practice Study, indicating a serious error rate of 3.7%, and the a study published in The Lancet, vol. 349, February 1, 1997, with the IOM study, To Err is Human, one can chronicle the increase from 3.7 to 17.3 to 25% in 2002) 6,7-and all of this happened to real honest-to-god human beings whose lives were snuffed out (if the IOM study is anywhere close to accurate, at least 380,000 to 980,000 people died from errors in that period) and millions more were permanently injured. 1 Ignorance, compounded by arrogance, fueled by greed is deadly.

And now another fact has hit health care's financial leaders: America's businesses have caught on, and they are appalled. Major employers formed the Leapfrog Group-and they want and demand safe care or they send their employees elsewhere. 8 America's regulators, stung by the criticism that they did not do enough to protect patients from profiteers, are working overtime to tighten the regulatory noose around the necks of the irresponsible.

Now, faced with growing shortages of personnel, astounding increases in malpractice insurance, daunting regulation-and once again, double-digit inflation-America's hospitals are struggling to regain lost ground. 9 To make hospitals places where people want to work, to put excellent clinical care back at the top of their priority list, and to pay more attention to safety of care than market share. Along with this, we are seeing hospitals, hundreds of them, seeking "Magnet status" and an interesting increase in the number of nurses serving as chief operating officers, and of both nurses and physicians serving as CEOs of hospitals and health care systems. (The Magnet Recognition Program was developed by the American Nurses Credentialing Center [ANCC], a subsidiary of the American Nurses Association [ANA], in 1994 to recognize health care organizations that provide the very best in nursing care and support professional nursing practice. The program also provides a vehicle for the dissemination of successful practices and strategies among nursing systems.). Community service is once again emerging as the real mission of the hospital-and with it, community support. The hospital's OFOR is turning around-and successful hospitals are turning both their clinical care and their bottom line around in spite of today's hostile environment. They are modeling the future: a hope-filled and sustainable future.

REFERENCES